At its meeting in Vancouver,
BC, Canada, in May 1994, the Executive Council of ISSD adopted
"Guidelines for Treating Dissociative Identity Disorder (Multiple
Personality Disorder) in Adults (1994)." The guidelines present a broad
outline of what has thus far seemed to be effective treatment for
dissociative identity disorder. The guidelines are not intended to
replace the therapist’s clinical judgment, but they do aim to summarize
what most commonly has been found to benefit dissociative identity
disorder patients. Where a clear divergence of opinion exists in the
field, the guidelines attempt to present both sides of the issue.

Guidelines like these are
never finished. This revision is the first since the adoption of the
guidelines in 1994. The Executive Council is aware of several areas that
the present guidelines overlook, such as partial hospitalization/day
treatment programs and the treatment of children with dissociative
identity disorder. In addition to adding new domains, future revisions
of the guidelines will take account of new knowledge arising in the
dissociative disorders field.

The guidelines were written
by the members of the ISSD Standards of Practice Committee, a diverse
and opinionated group who nevertheless found much common ground.
Following seven revisions in three years, the committee invited input
from ISSD members by publishing a draft in the October 1993 ISSMP&D
News. I received about 100 letters from members of the society. Most of
the respondents liked the document but wanted minor changes. I
summarized their comments and passed on another draft to the committee
members. The committee’s feedback was incorporated into a final draft
that received minor changes from the Executive Council. The Executive
Council updated the guidelines in 1996.

I would like to thank the
members of the committee for their contributions. Writing this document
was a time-consuming and exacting job requiring thought, creativity, and
tact from all contributors. I would also like to thank members of ISSD
who sent comments after reading the draft published in ISSMP&D News. I
hope that ISSD members will continue to provide suggestions and comments
to the Executive Council to aid in the next revision of the guidelines.

Given the complexity of
dissociative disorders, patients have been frequently misdiagnosed for a
period up to 20 or more years. However, considerable progress has been
made in the diagnosis, assessment, and treatment of dissociative
disorders during the past decade, as reflected by increased clinical
recognition of dissociative disorders, the publication of numerous
scholarly works focusing on the subject, and the development of
specialized diagnostic instruments. As there are at present no
controlled outcome studies of different treatment regimens, future
research, depending upon the use of new specialized clinical and
research tools, will further add to our present understanding of the
efficacy of the various therapies for the dissociative disorders.

The guidelines attempt to
summarize the numerous publications on the dissociative disorders,
including case reports, open clinical trials, and investigations
utilizing standardized tools. The guidelines reflect current scientific
knowledge and clinical experience specific to diagnosing and treating
dissociative identity disorder (DID), supplementing generally accepted
principles of psychotherapy and psychopharmacology.

Given the fact that ongoing
research on the diagnosis and treatment of dissociative disorders will
undoubtedly lead to further developments in the field, therapists are
advised to consult relevant published literature subsequent to the
publication of these guidelines. It should be noted that the guidelines
are not intended to dictate the treatment of specific patients, as
treatment should always be individualized. Therapists should always
conform to the local mental health code and related laws, as well as to
ethical principles of their professional disciplines.

Accurate clinical diagnosis
of the dissociative disorders allows for early and more appropriate
treatment and may be supplemented by standardized tests. Such tests,
while not designed to replace the clinician’s judgment, may provide
additional information critical to both diagnosis and/or adequate
treatment planning. A mental status examination augmented with questions
concerning dissociative symptoms is an essential part of the diagnostic
process. Specifically, the patient should be asked about episodes of
amnesia, fugue, depersonalization, derealization, identity confusion,
and identity alteration (Steinberg, 1995) as well as age regressions,
autohypnotic experiences, and hearing voices (usually internal) (Putnam,
1991).

Screening tools such as the
Dissociative Experience Scale, Dissociation Questionnaire, Questionnaire
of Experiences of Dissociation and informal office interviews are
available to identify patients who are at risk for a dissociative
disorder (Bernstein & Putnam, 1986; Loewenstein, 1991; Riley, 1988;
Vanderlinden, Van Dyck, Vandereycken, Vertommen, & Verkes, 1993). While
some investigations also indicate that psychological testing, such as
the Rorschach, may help to improve understanding of the patient’s
personality structure (Armstrong, 1991), other investigators note that
the use of tools such as the MMPI and WAIS-R contribute to misdiagnosis
of dissociative disorders (Bliss, 1984; Coons & Sterne, 1986). As
screening tools and psychological tests are not able to diagnose the
dissociative disorders, identified patients should then be evaluated
further to rule out a dissociative disorder utilizing more comprehensive
methods.

Structured interviews for
the detection of dissociative disorders are now available and can be
used to confirm a clinician’s diagnosis or to identify a previously
undetected case. Such tools include the Structured Clinical Interview
for DSM-IV Dissociative Disorders-Revised (SCID-D-R) (Steinberg 1994a,
1994b), which allows clinician to systematically evaluate and document
the severity of specific dissociative symptoms and disorders, and the
Dissociative Disorder Interview Schedule (Ross, 1989), a highly
structured interview developed to diagnose dissociative and other
psychiatric disorders. Investigations using a diagnostic interview
demonstrate that the diagnosis of dissociative identity disorder can now
be made as reliably as any other psychiatric diagnosis for which a
structured interview exists.

The existence of
dissociative identity disorder might also be unexpectedly revealed
during hypnotherapeutic treatment of another condition. Patients with
dissociative identity disorder who are diagnosed by using hypnosis do
not differ with respect to diagnostic criteria and symptoms from
dissociative identity disorder patients diagnosed without hypnosis (Ross
& Norton, 1989). When alternative diagnostic measures have failed to
yield a definite conclusion and diagnosis is necessary or in situations
of urgency when the establishment of a diagnosis is a matter of medical
necessity, hypnosis or amytal interviews may be helpful. However, it
should be noted that amytal and hypnosis, which alter the patient’s
state of consciousness, may yield symptoms that mimic dissociative
pathology in patients who do not have DID. Such procedures should avoid
leading and suggestive questions and should be used by trained
practitioners.

Depending on individual
circumstances, treatment teams may include a variety of professional
disciplines. Goals are symptom stabilization, control of dysfunctional
behavior, restoration of functioning, and improvement of relationships.
These goals must be addressed in an ongoing way, both through direct
approaches and through psychotherapeutic work that leads to increased
coordination and integration of mental functioning. Close coordination
with other medical specialists may be required when there are;

When comorbidity is a
problem, the associated diagnoses may require specific treatments.
Frequent diagnoses in this category include addictions, eating
disorders, sexual disorders, mood disorders, and anxiety. Treatment
plans may also include psychoeducational interventions, especially when
illness has intruded on normal development. Such interventions may
include retraining, education, bibliotherapy, expressive therapies, and
other treatments. Patients may have multiple legal involvements, which
also may require supportive intervention. In patients who have legal
involvement, it is wise to try to avoid planned therapeutic
interventions that may compromise the credibility of the patients in
forensic proceedings at a later point in time.

The dissociative identity
disorder patient is a single person who experiences himself/herself as
having separate parts of the mind that function with some autonomy. The
patient is not a collection of separate people sharing the same body.
The terms personality and alter (short for alternate personality) refer
to dissociated parts of the mind that alternately influence behavior in
dissociative identity disorder patients. Some clinicians prefer terms
such as disaggregate self state, part of the mind, or part of the self.

Wherever possible, treatment
should move the patient toward a sense of integrated functioning.
Although the therapist often addresses the parts of the mind as if they
were separate, the therapeutic work needs to bring about an increased
sense of connectedness or relatedness among the different alternate
personalities. Thus, it is counterproductive to urge the patient to
create additional alternate personalities, to urge alternate
personalities to adopt names when they have none, or to urge that
alternate personalities function in a more elaborated and autonomous way
than they already are functioning in the patient. It is
counterproductive to tell patients to ignore or get rid of alternate
personalities. Also, the therapist should not play favorites among the
alternate personalities or exclude unlikable or disruptive personalities
from the therapy, although such steps may be necessary for a period of
time at some stages in the treatment of some patients.

Additionally, the
dissociative identity disorder patient is a whole person, with alternate
personalities of adult patients sharing responsibility for his or her
life as it is now. In the psychotherapeutic setting, therapists working
with dissociative identity disorder patients generally ought to hold the
whole person to be responsible for the behavior of all of the alternate
personalities.

B. Framework for
Outpatient Treatment

The optimal primary
treatment modality for dissociative identity disorder is usually
individual outpatient psychotherapy. Although the patient’s feelings and
preferences need to be explored while devising and implementing a
treatment plan, the therapist, not the patient, ought to be the primary
architect of the treatment plan. The minimum number of sessions provided
per week should reflect the patient’s functional status and stability.
The minimum recommended frequency of sessions for the average
dissociative identity disorder patient with a therapist of average skill
and experience is twice a week. Some therapies, especially with patients
of high motivation and strength, can be conducted on a once-a-week basis
either with a single prolonged session or with a single session. Some
therapists of considerable skill and experience are able to treat many
such patients in once-a-week psychotherapy. With some patients, a
greater frequency of scheduled sessions (up to three per week) aids the
patient in maintaining the highest possible level of adaptive behavior
and (as an alternative to hospitalization) in containing disruptive
behavior. For patients newly discharged from inpatient treatment, a
period of sessions at a greater frequency may sometimes be necessary to
help the patient make the adjustment from the high frequency of sessions
provided in many inpatient programs. If more than three sessions per
week are routinely provided, the therapist should note the risk of
fostering regressive dependence on the therapist.

Marathon, or lengthy
sessions (i.e., sessions longer than 90 minutes), if used, should be
scheduled, structured, and have a specific focus such as completion of
amytal- or hypnosis-assisted processing of traumatic memories and
imagery, or administration of a diagnostic battery. Lengthy sessions may
also be used judiciously for the provision of structure and support in
dealing with difficult material. They may also be indicated when
logistics force the patient to come to the therapist infrequently, but
to work intensely when there.

Opinions diverge on the
length of treatment. Early anecdotal reports on treatment outcome showed
that over 2-3 years of intensive outpatient psychotherapy, patients
could reach a relatively stable condition in which they did not
experience a sense of internal separateness. However, most therapists
now see 3-5 years following the diagnosis of dissociative identity
disorder as a minimum length of treatment, with many of the more complex
patients requiring 6 or more years of outpatient psychotherapy, often
with brief inpatient stays during crises. The length of treatment varies
with the complexity of the patient’s dissociative pathology, usually
lengthening with severe Axis II pathology or other significant comorbid
mental disorders.

The most commonly cited
treatment orientation is psychodynamically aware psychotherapy, often
eclectically incorporating other techniques (Putnam & Loewenstein,
1993). For example, cognitive therapy techniques can be modified to help
patients explore and alter dysfunctional trauma-based belief systems;
however, standard cognitive therapy protocols for depression and anxiety
usually require modification when used in the treatment of dissociative
identity disorder. Most therapists employ hypnosis as a modality in the
treatment of dissociative identity disorder (Putnam & Loewenstein,
1993). The most common uses of hypnosis are for calming, soothing,
containment, and ego strengthening.

Behavioral analysis, or
operant conditioning, has not been shown to be an optimal primary
modality for treating dissociative identity disorder. Aversive
conditioning is particularly not recommended because the therapeutic
relationship and treatment procedures may unconsciously resemble abusive
experiences. However, behavior modification techniques may be useful
when taught to the patient as self-control techniques for symptom
management.

C. Inpatient Treatment

There is general agreement
that inpatient treatment for dissociative identity disorder should be
used for the achievement of specific therapeutic goals and objectives.
Treatment should occur in the context of a goal-oriented strategy
designed to restore patients to a stable level of function so that they
can resume outpatient treatment expeditiously. This remains the case,
whether the hospitalization is emergent or planned, on a specialized or
a general psychiatric unit. Efforts should be made to identify what
factors have destabilized or threaten to destabilize the dissociative
identity disorder patient and to determine what must be done to
alleviate them, if possible, and to minimize their impact. Emphasis
should be placed on building strengths and skills to cope with the
destabilizing factors. Optimally, these interventions should be planned
and contracted for prior to or very early during an admission, but it is
acknowledged that this may not be possible. Planned judicious processing
of traumatic material (sometimes called abreactive work), confronting
traumatic material in the supportive structure of a hospital setting,
and working with aggressive and self-destructive alters and their
behaviors are frequent concerns.

There is a general agreement
that decompensation or failure to improve during a hospitalization may
occur in several circumstances. There is consensus that dissociative
identity disorder patients often require hospital care for other
intercurrent mental disorders, such as major depression or anorexia
nervosa. There is consensus that a small minority of dissociative
identity disorder patients, including massively decompensated and
dysfunctional individuals, and those destabilized by severe present-day
trauma, may require prolonged inpatient treatment in order to be
restabilized. Treatment-related factors that may impede clinical
improvement include unfocused inpatient treatment or inpatient treatment
with global and unrealistic goals, such as “getting out all of the
memories,” an exclusive focus on past traumatic material to the
exclusion of contemporary issues, or pushing for rapid integration early
in treatment.

There is a divergence of
opinion as to whether brief stays are less likely to be associated with
regressive dependency than longer stays. Some find instances in which
they suspect that longer hospital stays are conducive to regression.
Others find instances in which it appears that a pressure to keep
hospital stays short leads to discharge of the patient in an
insufficiently stable state and at greater risk for readmission or undue
suffering. Regardless of the length of the patient’s hospitalization,
the therapist should maintain a stance that encourages progression and
independence.

There is agreement that
dissociative identity disorder patients optimally should be treated in a
manner that prepares them to do the work of therapy on an outpatient
basis, including processing traumatic material when necessary. There is
also agreement that for some overwhelmed patients and for a variety of
patients under some circumstances, the structure and safety of a
hospital setting make possible therapeutic work that would be impossible
or prohibitively destabilizing in an outpatient setting.

D. Group Therapy

Group psychotherapy is not a
viable primary treatment modality for dissociative identity disorder.
However, some believe that time-limited groups are a valuable adjunct to
individual psychotherapy in promoting a sense in patients that they are
not alone in coping with dissociative symptoms and traumatic memories.
Carefully structured groups with a high leader-to-patient ratio, a clear
focus, and clear time frames seem indicated. Some have found that
open-ended therapy groups promote acting out among the group members and
do not have a positive outcome; others report that such groups have been
a helpful adjunct to individual psychotherapy, particularly where the
leader describes clear expectations in areas such as extra-group contact
among members and therapeutic boundaries (see Appendix 1). Some patients
utilize 12-step groups effectively as an adjunct to their individual
psychotherapy. Marathon groups (i.e., longer than 2 or 2_ hours) may
prove destabilizing for some dissociative identity disorder patients.

E. Electroconvulsive
Therapy

ECT has not been shown to be
an effective or appropriate treatment for dissociative disorders, but it
may be important in relieving an associated refractory depression.

F. Psychosurgery

There is no evidence to
support the use of psychosurgery in the treatment of dissociative
identity disorder.

G. Pharmacotherapy

Psychotropic medication is
not a primary treatment for dissociative disorders, and specific
recommendations for pharmacotherapy of dissociative disorders await
systematic research. However, anecdotal reports support the use of
various medications for purposes such as treating some anxiety-related
dissociative symptoms, posttraumatic stress disorder symptoms, and
coexisting affective symptoms or disorders. Most therapists treating
dissociative identity disorder report that their patients have received
medication as one
element of their treatment (Putnam & Loewenstein, 1993). Therapists
prescribing medication need to make patients aware when any medication
protocol is experimental in nature, following applicable ethical and
legal guidelines. Doctors who prescribe medication and therapists who
treat patients on medication need to be aware that personality states
within the same patient may report different responses and side effects
to the same medication.

H. Therapist telephone
availability

Because many dissociative
identity disorder patients are prone to crises at certain points in
treatment, patients need a clear statement about the therapist’s
availability in emergencies. Generally, offering regular, unlimited
telephone contact is not helpful, but providing for limited availability
to the patient on a predefined basis is essential. Except under unusual
circumstances, regular calls initiated by the therapist to check in with
the patient are not recommended. The payment policy for telephone
contact should be discussed with the patient in advance wherever
possible.

I. Scheduling extra
sessions

Although extra sessions are
sometimes needed, when the patient frequently requests or requires the
scheduling of extra sessions because of crises, the therapist needs to
examine whether the patient perceives the scheduled frequency of
sessions to be adequate for his or her needs. As in any requested
gratification of a patient’s need, the therapist needs to examine such
requests in the light of the patient’s unconscious wishes for
reparenting or for other emotional gratification from the therapist.
Repeated crises may also reflect the patient’s inability at that time to
function outside a structured full or partial hospital setting.

J. Physical contact

Physical contact with a
patient is not recommended as a treatment technique. Therapists
generally need to explore the meanings of patient requests for hugs or
hand-holding, for example, rather than fulfilling these requests without
careful thought and consideration. Simulated breast-feeding or bottle
feeding are unduly regressive techniques that have no role in the
psychotherapy of dissociative identity disorder. Some therapists find
that for some patients undergoing planned abreactions, holding the
patient’s hand or resting a hand on the patient’s arm may help the
patient stay connected to present-day reality. However, other therapists
feel that patients may misinterpret such contact and that it should be
avoided. Some patients may seek out massage therapy or other types of
body work; the risks and timing of such work should be carefully
discussed with the patient and the adjunctive therapist.

Sexual contact with a
current patient is never appropriate or ethical. Laws and ethical
standards of the various healthcare disciplines regulate such contact
with a past patient. Because dissociative identity disorder patients
have a relatively high vulnerability to exploitation and because of the
intensity of the therapeutic interactions that dissociative identity
disorder patients have with their therapists, any sexual contact a
therapist might have with his or her former dissociative identity
disorder patient would be likely to be exploitive and therefore
inappropriate.

K. Physical restraint

There is a divergence of
opinion on the value of voluntary physical restraint in treatment. Some
believe that the technique is a helpful last resort when physically
aggressive or self-destructive alternate personalities are otherwise
unable to participate in therapy. Others believe that voluntary physical
restraint is inappropriate and that verbal techniques will suffice to
involve all the personalities in therapy. If physical restraint is being
used with great frequency and/or for prolonged periods, the therapist
should reassess the pace of the therapy and the dynamics of the
patient-therapist relationship.

In inpatient treatment,
seclusion and physical restraint may be indicated for the dissociative
identity disorder patient who is acting out violently and has not
responded to verbal or pharmacological interventions. These treatment
modalities should always be applied in accordance with the legal and
ethical standards applicable to the inpatient unit and the professional
disciplines involved in implementing them.

L. Hypnotherapy

dissociative identity
disorder experts generally agree that hypnotic techniques can be useful
in crisis management to help patients terminate spontaneous flashbacks
and reorient themselves to external reality when these states occur
outside therapy. Hypnotic techniques are also useful for ego
strengthening and for supporting dissociative identity disorder patients
during crises, and to help patients remain stable between sessions in
which they are recalling or discussing traumatic material. Other
commonly described uses of hypnosis include its roles as an aid in the
safe expression of feelings (e.g., the “silent abreaction” for the
release of anger), cognitive rehearsal and skill building, relief of
painful somatic representations of traumatic material, and fusion
rituals (when previous psychotherapeutic work has caused a particular
separateness to no longer serve a meaningful function for the patient’s
intrapsychic and environmental adaptation and when the patient is no
longer narcissistically invested in maintaining the particular
separateness). In the hospital, staff can be trained to calm the patient
exhibiting violent behavior by means of temporizing techniques but
without using formal hypnosis unless credentialed to do so by the
hospital (Kluft, 1992). When these techniques are employed, the patient
is generally informed beforehand and the intervention becomes part of
the nursing treatment plan.

There is a divergence of
opinion concerning the role of hypnosis in the ongoing psychotherapy of
dissociative identity disorder. Some believe that hypnotic techniques
are useful in increasing communication between alternate personalities
or in bringing alternate personalities into communication with the
therapist. Some believe that hypnotic techniques are useful in memory
retrieval; others believe that hypnotically facilitated memory
processing increases the patient’s chances of mislabeling fantasy as
real memory and increases the patient’s level of belief in “retrieved”
imagery that may actually be fantasized. The therapist needs to be aware
that hypnosis induced by the therapist may leave patients with an
unwarranted level of confidence in the accuracy of the details in
hypnotically retrieved material. The therapist should minimize the use
of leading questions that may in some cases alter the details of what is
recalled in hypnosis.

The therapeutic use of
hypnosis should be conducted with appropriate informed consent provided
to the patient concerning its possible benefits, risks, and limitations.

M. Veracity of the
patient's memories of child abuse

Frequently, dissociative
identity disorder patients describe a history of abuse, usually
including sexual abuse, beginning in childhood. Many dissociative
identity disorder patients enter therapy having continuous memory for
some abusive experiences in childhood (Barach, 1996; Ross et al., 1990).
In addition, most also recover memories of additional previously unknown
abusive events, with recovery of material occurring both inside and
outside of therapy sessions, and sometimes prior to the commencement of
psychotherapy. Discussion of this material and its relationship to
present beliefs and behaviors is a central aspect of the treatment of
dissociative identity disorder.

Clinicians and researchers
have issued several statements concerning recovered memories of abuse
(American Psychiatric Association, 1993; Australian Psychological
Society Limited Board of Directors, 1994; Working Group on Investigation
of Memories of Childhood Abuse, 1996; Working Party, 1995). These
statements all concluded that it is possible for accurate memories of
abuse to have been forgotten for a long time, only to be remembered much
later in life. They also indicate that it is possible that some people
may construct pseudomemories of abuse and that therapists cannot know
the extent to which someone’s memories are accurate in the absence of
external corroboration. Patients’ recall of child abuse experiences, as
well as their recall of other experiences, may at times mix literal
truth with fantasy, confabulated details, or condensations of several
events. Therapy does not benefit from telling patients that their
memories are false. Neither does therapy benefit from telling patients
that their memories are accurate and must be believed. A respectful
neutral stance on the therapist’s part, combined with great care to
avoid suggestive and leading interview techniques, seems to allow
patients the greatest freedom to evaluate the veracity of their own
memories.

There is a divergence of
opinion in the field concerning the origins of patients’ reports of
seemingly bizarre abuse experiences. Some believe that patients’ reports
can be the result of extremely sadistic events experienced by the
patient in childhood, perhaps distorted or amplified by the patient’s
age and traumatized state at the time of the abuse. Others believe that
alternative explanations suffice to explain these patients’ reports.
Therapists who take extreme positions on either side in the therapy
setting may diminish the likelihood of timely progress toward the
patient’s clarification of the historical accuracy of such memories.

N. Management of
Traumatic Memories (abreactions)

Traumatic material may
surface spontaneously, or its processing may be planned; both situations
occur in the treatment of dissociative identity disorder patients. The
use of planned processing of traumatic material (abreactions) is a
treatment technique of value with many patients but is not a therapy in
itself. Patients benefit when the therapist helps them use planning,
information, exploration, and titration strategies to develop a sense of
control over the emergence of traumatic material. When patients
spontaneously experience intrusive traumatic imagery, they often benefit
from learning strategies that help them delay or control the level of
intrusiveness of the traumatic material into their daily functioning.
However, some patients develop such control more rapidly than others.

Clinicians experienced in
treating dissociative identity disorder agree that therapeutic attention
to emergent traumatic material is an essential part of the resolution of
dissociative pathology. Ignoring this material does not make it “go
away,” although the timing and nature of therapeutic attention paid to
this material will vary according to the needs of each patient.

Many clinicians believe that
occasionally extending preplanned trauma memory-processing sessions
beyond their usual length is of distinct value in the treatment of some
patients. At certain times such a session will unavoidably extend past
its scheduled endpoint, but the therapist should try to minimize this.
Therapists need to attempt to help patients to reorient themselves to
external reality and end processing of traumatic memories before the
scheduled end of therapy sessions, although they can only influence,
never control, the patient’s ability to reorient to the present.

O. Nonverbal adjunctive
therapeutic approaches

Like other victims of
childhood trauma, dissociative identity disorder patients are often
uniquely responsive to nonverbal approaches. Art therapy, occupational
therapy, sand tray therapy, movement therapy, other play therapy
derivatives, and recreational therapy are reported as helpful toward
achieving treatment goals, including integration. Nonverbal therapies
need to be conducted by appropriately trained persons and be well timed
and well integrated into the overall treatment plan. Many
psychotherapists find nonverbal techniques (such as patients’ drawings
and journals) useful as part of ongoing psychotherapy.

In all interactions with the
media concerning dissociative identity disorder, the therapist’s primary
responsibility remains the welfare of his/her patients. Thus, the
therapist must maintain the highest ethical and legal standards of
confidentiality with respect to clinical material.

Appearances by patients in
public settings with or without their therapists, especially when
patients are encouraged to demonstrate dissociative identity disorder
phenomena such as switching, may consciously or unconsciously exploit
the patient and can interfere with ongoing therapy. Therefore, it is
generally not appropriate for a therapist actively to encourage patients
to “go public” with their condition or history.

Like other victims of trauma
by human agency, dissociative identity disorder patients may struggle
with questions of moral responsibility, the meaning of their pain, the
duality of good and evil, the need for justice, and basic trust in the
benevolence of the universe. When patients bring these issues into
treatment, ethical standards for the various professional disciplines
specify the need to conduct treatment without imposing one’s own values
on patients. Although patients may experience certain personalities as
demons and as not-self, therapists should approach exorcism rituals with
extreme caution. Exorcism rituals have not been shown to be an effective
treatment for dissociative identity disorder, have not been shown to be
effective for “removing” alternate personalities, and have been found to
have deleterious effects in two samples of dissociative identity
disorder patients that experienced exorcisms outside of psychotherapy.
Exorcism rituals may provide a way for some patients to rearrange images
of their personality systems in a culturally syntonic manner. Education
and coordination between therapist and clergy can be helpful in ensuring
that patients’ religious and spiritual needs are addressed.

Because many dissociative
identity disorder patients may have difficulty in parenting and a
minority admit to being abusive toward their children, and also because
dissociative identity disorder may involve a biological predisposition
to dissociate, some have recommended that the children of dissociative
identity disorder patients be assessed by a therapist familiar with
dissociative disorders and indicators of child abuse. Other family
interventions, such as couples therapy and sibling group sessions, may
be indicated.

Victims of child abuse or
neglect have generally grown up in situations where personal boundaries
were either not established or were invaded. For this reason, their
treatment ought to include a therapeutic relationship with clear
boundaries. The therapist is responsible for clearly defining such a
therapeutic relationship.

Boundary issues arise
throughout treatment, with negotiation and discussion of these issues
occurring as needed. Most experts agree that the patient needs a clear
statement near the beginning of treatment concerning therapeutic
boundaries. This statement may not always be understood immediately by
the patient, may take several sessions to convey, and may require
repetition at various points in the therapy. The discussion concerning
therapeutic boundaries might include some or all of the following
issues: length and time of sessions, fee and payment arrangements, the
use of health insurance, confidentiality and its limits, therapist
availability between sessions, procedure if hospitalization is
necessary, patient charts and who has access to them, the use (or
nonuse) of physical contact with the therapist, involvement of the
patient’s family or significant others in the treatment, discussion of
the therapist’s expectations concerning management by the patient of
self-destructive behavior, legal ramifications of the use of hypnosis as
part of the treatment (i.e., material recalled in trance is not likely
to be admissible evidence in any legal action undertaken by the
patient), among others.

Treatment should ordinarily
take place in the therapist’s office. It is not appropriate for a
patient to stay in the therapist’s home or for members of the
therapist’s family to have ongoing extratherapeutic relationships with
the patient. Treatment usually occurs face to face instead of on the
analytic couch, though the latter is also acceptable for therapists with
psychoanalytic training. Treatment should ordinarily take place at
predictable times, with a predetermined session length under most
circumstances. Clinicians experienced in treating dissociative identity
disorder generally strive to end each session at the planned time.

Therapists need to follow
relevant legal and ethical codes with respect to gifts exchanged by the
therapist and patients, dual relationships, and informed consent for
treatment.